Tuesday, March 28, 2017

From redesigned first-aid kits to a radically new kind of surgery on the front lines, battlefield medicine has changed markedly and, as a result, doctors in the war in Iraq hope to significantly reduce the death rate from battlefield wounds -- a rate that has not budged for 150 years.

Since the Civil War, experts in military medicine say, one of five wounded soldiers has died, half from profuse bleeding. Pentagon doctors hope to change that, and have mobilized an array of innovations.

Some, like putting pressure bandages in first-aid kits, are drugstore cheap. Others, like a new anticlotting drug for internal bleeding, are high-tech expensive, about $7,000 per dose. And some, like sending radically redesigned surgical teams to operate at the front lines, involve tactics and equipment that simply were not available in the last gulf war. These special surgery units were tested in Afghanistan, where they reduced the died-of-wounds rate, the death rate for those who survived long enough for a surgeon to operate, to a fraction of a percent. For the past half-century, it has hovered around 2 percent.

Doctors said it was hard to overestimate the difference.

There was little change from Vietnam to the first gulf war in doctors' instruments, drugs, techniques or tactics. Except for some in the Army, which put surgeons in the front lines in Desert Storm, wounded soldiers received first aid from medics but no surgical care until they were evacuated to a larger hospital.

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Now, all the services have small mobile surgical teams scattered throughout the battlefield, where they operate on the most severely wounded as close to the front as possible. They do the minimum operation to stabilize patients for evacuation to a larger hospital. There, they may have another operation to further stabilize them for evacuation to a hospital in Europe.

''Never before in modern warfare have we done things so differently,'' said Lt. Col. Donald Jenkins, a surgeon who is chief of trauma at Wilford Hall Air Force Medical Center in San Antonio.

Many of the patients treated have been Iraqis. ''By Geneva Convention and NATO standards, casualties are taken care of in order of priority, based on injury and illness, not based on uniform,'' Dr. Jenkins said. ''That's been the policy back to our own Civil War at least.''

Col. John Holcomb, a surgeon who directs the Army Institute of Surgical Research in San Antonio, said some of the innovations came from after-action reviews in which doctors analyzed data on why soldiers died, where they died, and how.

Each branch of the service makes its own decisions about which innovations to adopt. For example, the Marine Corps has added a new product, QuikClot, to every marine's first-aid kit, said Lt. Cmdr. Joe DaCorta, who is in charge of expeditionary medicine at the Marine Corps Warfighting Lab in Quantico, Va.

The substance was tested for battlefield use by Dr. Hasan Alam, a trauma surgeon at the Uniformed Services University of the Health Sciences in Bethesda, Md. Dr. Alam said he was haunted by troops who bled to death in Somalia before surgeons could help them.

For Dr. Alam, it meant that ''your buddy has to stop the bleeding, not the medic, not the surgeon.''

So he turned to QuikClot, a product made of the mineral zeolite and sold over the counter by Z-Medica. It looks like cat litter but, sprinkled on a wound, it absorbs water from blood, concentrating the body's own clotting factors and speeding up the formation of a clot.

Z-Medica has supplied 50,000 doses to the military.

Dr. Alam and his colleagues tested the substance on 36 Yorkshire swine, which are close to a person's size. The results have not been published, but Dr. Alam said QuikClot converted wounds that were 100 percent fatal into wounds that were 100 percent nonfatal -- clots formed and none of the animals died.

Although the Marine Corps plans to use it, other branches of the military are not yet convinced. The question is whether to use it, and at what dose. One concern is that heat is generated when QuikClot is poured on a wound, and the fear is that it might burn tissue. ''We don't have a huge amount of data,'' Dr. Alam said. ''We've done two studies.''

Also, the troops must be trained in how to use it and surgeons must be trained about what to expect.

Meanwhile, the Army and the Special Operations forces are taking an additional approach to clotting, Colonel Holcomb said. They will use coated bandages to stop bleeding. One bandage, developed by the Red Cross, used two clotting proteins, fibrin and thrombin, to speed clot formation. The other, made by HemCon of Oregon, uses chitosan, a clot-promoting protein in shrimp shells.

Remaining problems include what to do about severe injuries to the abdomen or pelvis, which may cause rapid and uncontrolled internal bleeding, or bleeding in the brain from a head injury.

''What about an intravenous drug that could accelerate the hemorrhage-control process?'' Dr. Holcomb asked. The Army, he said, is considering using factor VIIa, a clotting drug recently approved for treating hemophilia. Animal studies, he said, indicate that it can work, and trauma centers often use it. The Defense Department and the company hope to conduct a clinical trial.

Military medical experts said the hope, with all of these new products, is that they will keep the wounded alive until they can see a surgeon.

Surgeons will be using a method pioneered a decade ago in trauma centers in cities reeling from an epidemic of drug-fueled violence.

One of its leading innovators was Dr. C. William Schwab, a trauma surgeon at the University of Pennsylvania, who was troubled by the number of patients treated there who died later.

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''We started to see that even though we would get the injury controlled and fixed, even though we put them back together, they would die,'' Dr. Schwab said. Patients would go into shock, their temperatures would drop, their blood would become acidic and coagulate, forming fatal clots.

Dr. Schwab decided to try doing the absolute minimum surgically to stop the bleeding, so doctors could turn their attention to stabilizing the patients. Later, he reasoned, surgeons would complete their repair.

Dr. Schwab named the method damage control, a Navy term he recalled from the 10 years he spent on an aircraft carrier in Vietnam. When a ship was hit, he recalled, the idea was to patch it up and keep it afloat, doing the major repairs later.

He tried it with trauma victims. ''We would control bleeding and any contamination from the GI tract,'' he said. ''Then we would continue to resuscitate them and bring them back in two or three days and do definite surgery.''

To assess the method, he compared patients treated with damage control with similar, seriously injured patients who had had traditional surgery. With damage control, 75 percent survived. With traditional surgery, almost every patient died. A decade later, after further refining of the technique, 90 percent are surviving, Dr. Schwab said.

As the approach spread in trauma centers across the country, military surgeons started showing up at Dr. Schwab's hospital for training.

''What I learned from Bill Schwab was absolutely indispensable,'' said Dr. Jenkins, who spent two years there. ''I took care of people who for sure in my training we would have looked at them and said, 'There is no way this person could survive.' '' Yet survive they did.

But to bring the technique to the battlefield, the military had to make major changes. First, it had to put the surgeons with the frontline troops, so they could do damage control surgery immediately.

The new idea was to keep a small surgical team on the front line, using a portable operating room that is set up in an hour for damage control surgery. From there, patients are stabilized and taken to hospitals for additional surgery days later.

It required making what once was bulky equipment light and portable, said Dr. Paul K. Carlton Jr., the recently retired surgeon general of the Air Force who now directs the Integrative Center for Homeland Security at Texas A & M. Today, Dr. Carlton said, surgeons can carry the equipment they need in a backpack.

For example, frontline units are equipped with sonogram machines the size of cassette recorders, and devices the size of a PDA that can do a complete laboratory analysis on a drop of blood.

Another piece of the plan is to train surgeons and support staff, and once again military doctors turned to urban trauma center. ''They have too many patients,'' Colonel Holcomb said. ''We need patients.''

In Miami, Dr. Tom Knuth, who directs the Army Trauma Training Center at Ryder Trauma Center, is training military general surgeons, plastic surgeons and other specialists and technicians and medics.

''They integrate with the civil staff to manage whatever patients come through the door -- bad motor vehicle crashes, gunshot wounds,'' Dr. Knuth said. ''And they get to work together as a team.'' With the war, the training regimen has been compressed from a month to 10 days.

Dr. Carlton said the war in Afghanistan showed what is possible. Of 250 seriously injured patients, only one died. ''It was the lowest died-of-wounds rate in the history of war,'' he said.

One man suffered a catastrophic wound to his rectum, prostate, anus and bladder. The ghastly injury plunged him into shock immediately, but one of the backpack surgical teams got to him right away and did a damage control surgery. Then, he was put on an airplane equipped as a critical care unit and flown a few thousand miles to another hospital for another surgery to stabilize him. Then he was flown to Germany for reconstructive surgery.

''He's home with his family now,'' Dr. Carlton said. In any other war, he added, ''he would have been dead.''